Happy Birthday, Jesse! He's 17 and in all the glory of adolescent angst. Jesse is a black hole of need. To make 17 all the harder, Jesse continues to deal with issues of identity and belonging. It's probably not the easiest age to be gay or to be discovering birth parents.

Jesse's relationship with Paul has gotten much better, much warmer. I liked when Paul told him he would gain strength from his struggle. Finally, he has something positive and encouraging to say to a patient. And he's tender with Jesse as the parallels continue with his own angsty relationship with his son, Max.

Frances spends the session grappling with her relationship with her dying sister and her angry teenage daughter. She wants Paul to feed her--she's hungry and he must have food, after all he lives here--but he refuses.

She leaves the stage to be with her sister after months of estrangement. They have a nice moment after Frances rescues the sister, bathes her, and puts her to bed. But it's short lived--the sister wakes up confused and needs to go to the hospital.

Frances has a tendency to look at all of her interactions as centering on herself. Her sister's warm declarations become meaningless when replaced by febrile mumblings. Paul's look is skeptical. She feels constantly judged and she looks for repeated approval and reassurance. Her daughter hates her, and it can't just be that the daughter is a teenager who is struggling with her aunt's terminal illness, her parent's divorce, and the tumultuous world of teenagers, it has to be about Frances. Ah, the teenager says Frances is a narcissist and that's untreatable. Is this true?

From my point of view, I don't believe that people change their personalities much. But therapy does seem to help people re-frame things, recognize their patterns, say "oh, I'm doing that again" and question what is going on. If I don't think I can "fix" something, I work on reframing it in a positive way. Most traits can be both good and bad, and the choice of words makes all the difference in the world. A shrink might tell Frances that it seems to be true that she likes being the center of attention, most actresses do, and it's a pretty helpful characteristic to have if you're going to be the star of the show. But maybe the sister's death isn't about Frances, and maybe she shouldn't take everyone else's distress too personally.

Julia comes in first. She was injured when Sunil pushed her and she says that he is worse. Treatment is not helping and she is no longer going to pay for it. Her husband will need to prescribe stronger medications for his father (or perhaps the houseplant).

Sunil continues to evade the questions. He sings in Bengali for Paul, a farewell song. When he says words in Bengali, Paul cuts him off, rather rudely, and tells him to speak English. Sunil asks Paul to keep an old cricket bat he's found; he might be tempted to use it to murder or maim or do something bad to Julia.

Paul is rather worked up during this session and he implores Julia to allow Sunil to continue in treatment. He further implores Sunil to keep coming. He offers to see Sunil pro bono, or to meet him outside the office for tea.

This episode requires that the viewer suspend disbelief in the realities of psychiatric treatment. It's a world with no psychiatrists, no hospitals, no rationale use of medications, no duty to prevent harm, and no sense that violence can come from a illness that one can't be talked out of. There is faith that treatment will ultimately lead to betterment, even when things are getting worse and the characters may not live through the day.

Sunday, November 28, 2010

I hope everyone had a wonderful holiday! We've been busy brining, basting, baking, eating, and visiting with family. Sad to go back to the daily routine.-----------------------

In today's NY Times Magazine the ethicist entertains the question of whether it's okay for a psychiatrist to lie to keep his clientele. (!)

I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?

I think that most of us would agree that it's not okay to lie with the intention of keeping business. What if a patient asks how long you've been practicing, and your sense is that the patient wants an experienced psychiatrist-- would it be okay to say 10 years, rather than 1 year? Clearly not.

Personal questions can be awkward, however. In traditional psychodynamic therapy, the therapist doesn't answer personal questions---the "blank screen" is necessary for the treatment, and the meaning behind the question is explored. This can be very off-putting to some patients, and for myself, I find that it feels disingenuous, and I prefer to simply answer questions. It helps that I don't get many questions: Do you have children is the most common, I've been asked my religion a couple of times, if I have a dog (Yes, two, would you like one?). Here and there, I've been asked rather unusual questions (Do I have a cook? Who has a cook? No, but I'd like one!)

It seems to me that if something like this is essential to the patient's comfort level, then they should ask this on the phone before the first session. Does it all matter? Who knows---they make good therapists in all shapes and sizes and the interpersonal fit often is found in the least expected place. And my guess is that the ability to accurately diagnose and treat a mental illness has relatively little to do with any of these matters. Probably people are more picky about the personal lives of their shrinks than their brain surgeons, but maybe they shouldn't be.

Wednesday, November 24, 2010

Roy talks about the Maryland Health Information Exchange (HIE) called CRISP, which stands for Chesapeake Regional Information System for our Patients. Note that your health information is accessible to participating health care providers unless you opt out. You can read more at CrispHealth.org. We ramble about the downside of sharing health information electronically. We also complain about how difficult it can be to get medical information now, so there are pros and cons.

Roy talks about career satisfaction of psychiatrists based on a survey done by Epocrates. Roy talks about the increasing job satisfaction of primary care docs -- it's going up! In psychiatry it's also going up, based on data now compared to 3 years ago. Happy shrinks are up to 83% from 70%. Roy encourages med students to join us. Dinah extols the wonders of the diversity of psychiatry. Read the article about the survey Here.

Dinah brings up the age old dilemma of how to write about clinical information in psychiatry without compromising patient confidentially. We talk about how we deal with this problem in Shrink Rap: Three Psychiatrists Explain Their Work. Ah, but it's not just printed matter, but blogging and tweeting and podcasting.

------------------------------------------
Roy thinks this was a mistake, that I didn't finish the post, but this was all I had to say. It was a contentious and uncomfortable session and by the end, I wanted to go home. Ah, I was at home! These people are not nice, and who would want to pay for this kind of confrontation, unleashed emotion, and discomfort. Paul is a handful, and now we hear his fantasies about a life together with Adele, and that he's watching her building (for an hour after the last session!) and knows she doesn't have any patients after him, so at 6 o'clock at night, she should be happy to extend his session. It's like Jesse, only at least we can excuse Jesse's immaturity as adolescence. And why is everyone in this show a stalker? I did not think that Adele did as a good a job as before: she openly sneared at Paul in the beginning, and she angrily confronted him with his refusal to look at the important things and his rigidity.

Just a hint: name calling makes people defensive. They are more likely to consider your thoughts if you couch them in kind terms or universal phenomena that make them easier to swallow: "it's difficult to look at your own weaknesses"..."there are parts of your style that serve you very well..."

High drama here on HBO. And Paul chases yet another patient out of his office.
Paul is making pancakes for dinner with his son, Max, and trying all-too-hard to connect with the quiet pre-teen. A knock at the door and it's patient Jesse, in distress. He needs an emergency session and Paul leaves Max to go to Jesse.

Jesse went to see his birth parents. He showed up early and there were kids in the yard. He left and returned at the appointed time, stoned. The kids were gone, without a trace, and one was in a wheelchair. Maybe the birth parents had searched for Jesse because they want his organs for the sick kid. Oh, and they asked Jesse to leave, perhaps because he asked them for money.

Paul confronts Jesse with his habit of testing people and using their failure as proof that Jesse is no good. It's a pattern, he's done it tonight by showing up at Paul's apartment. Injured, Jesse runs out with Paul yelling at him not to leave. We call this therapy? Paul follows Jesse and they sit on the steps more calmly. Until, the smoke detector goes off and Paul has to choose between Jesse and saving his son from the burning building (or rather, the burning pancakes). Everyone here needs a hug.

So what about the boundaries of the home office? And why doesn't Paul recognize that his timing sucks: when someone is in a state of distress, they need a little empathy, warmth, and kindness, not an interpretation of all their faults as a human being. I'd kind of like to take his batteries out about now.

Frances continues to be flirtatious and provocative. She insists that Paul open and read her cancer gene results, just as she tried to get him to run play lines with her, but this time he bites. The results are negative. They are both relieved, but the sparring continues.
Frances remains jealous that her daughter wants to be with her dying sister, Patricia (Paul's former patient of 20 years ago).

Last night, Frances had sex for the first time since her husband left her, with a man 20 years her junior. She seems to enjoy giving Paul the details.

And what happened between you and my sister, Frances asks Paul. She says you were in love with her. Were you? If Paul's not provoked by this, maybe he can see it through.

Frances isn't going to see her dying sister. Paul tries to explore this and he finally tells her, point blank, that she needs to go see her sister before she dies or she will regret it forever. This as he chases her to the door.

Why are Paul's patients always storming off with him on their tail?
-------------------
The chinchilla is for Jesse.

He feels like a prisoner in Brooklyn, while back home the monsoons are causing devastating floods. Paul believes that his problems could be fixed by better communication. Tell your son you want to move. Sunil is frustrated in his attempts to get Paul to understand his life. He can't leave, can't go home, and must stay put in his son's residence. Paul thinks Sunil could get a job and move into his own apartment. To make matters worse, Paul insists on talking about Sunil's dream, and Sunil gets outraged when Paul concludes that a character in the dream is the former girlfriend, despite Sunil's protests. So what else is new?

Sunil is convinced that his daughter-in-law is having and affair, and that she is mocking him-- something he finds humiliating. He is enraged and wants to smother her, or perhaps her laughter. He tries her bedroom door, and thinks of calling Paul in the middle of the night.

Paul is clearly worried, and he says so. He doesn't ever ask outright if Sunil is thinking of killing Julia. He talks to Sunil about what stress he is under, and just as I think he's going to suggest that Sunil go into the hospital, he recommends he come twice a week for therapy. It's certainly understandable that Paul would want to keep closer tabs on Sunil, but is digging deeper a good idea? The patient seems to be unraveling, and Paul tends to find the strands then pull and pull.

Friday, November 19, 2010

Recently there was a little problem in one of our local facilities. Nobody died, but the incident caused the officers in my facility to reminisce about fights they've had to break up in the past. I overheard some of the conversation and the result is this poem, direct from the officers' mouths:

Two of You and the Gate is Locked

200 guys in the yard, two of you and the gate is lockedYou had two fights over here, three fights over there, it was like May Day...It wasn't against us, it was BGF but we still had to stop itIt was over something small, one guy had a beefThat's when the weapons came outThe officer opened the gate to let him out"I couldn't stand there and see the guy stabbed up"They kicked the gate openThat's how the fight got to the compoundYou gotta contain itThe gates lock you ain't going no whereThey hit the doors, you contain itYou ain't going no whereYou in there

Grand Rounds in the medical blogosphere will be on Gratitude this week. Roy wants me to write a post on gratitude. ClinkShrink wants me to write a book about In Treatment. I am grateful I have friends to help me figure out how to spend my time and keep me off the streets. Does this count? Perhaps the Grand Rounds folks would like to read about In Treatment?
_______________
Great line, Adele to Paul: "At a certain point, you have to move past the stories you've assigned to your life."

Paul says he lacks passion, something that everyone else has. Adele, he says, has passion for this, this being her work. At first it seems a bit narcissistic....Paul is assuming she loves her work, because her work, after all, is talking to him, and no one wants to think that their therapist hates coming to work. But then we learn that Paul has Googled Adele, and part of why he assumes she loves her work is because she's written a lot-- she must have passion.

Adele is a bit stiff for my taste. I like animated people. But she's a good therapist for a fictional character--she's attentive and able to distill patterns, and she has good insights. So just as I'm thinking that Adele is such a much better example of a therapist than Paul is because she doesn't get in his face and say confrontational, contentious things, she blows it. Paul talks about how caring for his sick mother stifled his childhood, and Adele proposes that he may have used this as an excuse to hide. He says no, this doesn't feel right, but Adele insists it is. I hate it when they do that.

Finally, Paul was distracted during sex this afternoon. You knew he was thinking about Adele, that he has become attracted to her, and in this episode her eyes have become so much more flirtatious. New makeup or camera angles, I suppose? And at the end of the session, he tells her she's right when she says he holds back, and he tells her he's been thinking about her (during sex with his girlfriend). Textbook transference, he says, as though being a therapist himself should make him above all that. It's a compelling session, and we're left to wonder if Adele can hold her boundaries (we think so) and what will happen next week.

I'm grateful that someone somewhere might be interested in my thoughts on a TV show. Thank you for reading!

While reading Kim's excellent Doctor Who edition of the weekly Grand Rounds on Emergiblog, add to the ambience by listening to My Three Shrink's Dr Phil prank, which has a mashup of KLM's Doctorin' the Tardis song starting about 10 minutes into the 19 minute segment [4MB] (complete with Anne's maniacal laughing).

It's thundering outside, an extra component to this week's stormy session with Jesse.

Jesse is struggling as he copes with communications from both his birth parents. His adoptive parents were angry--- a sign that they want him. "I have ADD and I'm a slut. Who would want me? Would you?" Paul says "Yes." It was a nice thing to say, I'm not so sure I believe him. And he answers this charged question, but won't answer when Jesse asks if Paul likes the letter Jesse crafted to his birth parents. Both of Jesse's moms are depressed, it seems. Marissa hasn't gotten out of bed for a week-- not since her visit to Jesse's psychotherapy session, and Karen always gets depressed around his birthday, presumably out of grief that she gave her baby away.

Jesse is still cursing, but overall, he's become more insightful, less ready to charge, and less provocative. My satellite blitzed for the last few seconds of the show, so fill me in. Jesse leaves and Paul still has all the letters to and from Jesse's birth dad. And what's with the show opener where he's sniffing spices? Still trying to figure out if he has Parkinson's Disease? I guess it's the season-long personal life of the therapist theme.

Paul rejects Frances yet again. He wouldn't run lines with her last week, and this week he won't accept tickets to her play. He suggests she bring her sick sister or her estranged daughter, but Frances isn't biting.

She talks about how her dying mother came to see her in play; they celebrated with champagne. But the trip was hard on her mother and she feels guilty for having had her mother come at all. She was no good when mom was sick-- "inept" and vomited in the hospital sink. Her sister's illness has revived all these issue around death.

Who is Frances? She puts herself down and she can't accept a compliment. Fame and accolades and she goes home to a dark apartment and soup from a can. She checks her makeup in the mirror before she leaves the session and worries about who might be in the waiting room. She feels like a empty receptacle that can never be filled.

Sunil remains kind of creepy. He sneeked into his daughter-in-law's private study and found her birth control pills---proof, he says, that she's having an affair. Is he delusional? And he had this disturbing dream where he was burying an animal, one that had fallen from a cliff, and when he awoke, he went to his son's bedroom and watched him and his wife sleep. For fifteen minutes. Really creepy.

We learn that Sunil's former lover broke off their relationship on the library steps and then threw herself off a bridge. He was questioned when the police investigated her death, an apparent suicide.

Paul continues to confront Sunil. The birth control pills might not be proof of an affair. Sunil wants to change the subject and Paul stops him. The relationship Sunil had with his lover is similar to his son's relationship with his wife, and this is why Sunil is so troubled by it. When the patient disagrees, Paul does not back down--- he tells Sunil how it is. Does anyone else find it insulting when a therapist insists that a patient feels something he says he doesn't? Sunil considers Paul's theory, thanks him and leaves.

Paul is clearly worried about what Sunil may do. Call if you have disturbing thoughts. The frustration of both parties is palpable--- at times, Sunil raises his voice in an effort to be heard, especially about his right to snoop in his daughter-in-law's study. And Paul....well, Paul always looks frustrated.

Monday, November 15, 2010

A while back, I put up a YouTube video that I thought was funny. A commenter didn't like it and felt it promoted stigma. So I took a vote, and while most people were fine with it, a number did not like it, and I took the post down. We received this note, and I thought it was substantial enough to be it's own guest post (with permission, of course).------------------

Hi. I am a practicing psychiatrist based in New York City. I find your blog interesting, informative, and, at times, funny. Now, can you guess which entry I'd like to comment on?

Mel Brooks once said, (paraphrased), that if you slip on a banana peel and land on your butt, it's comedy. If I fall down a flight of stairs, it's tragedy.

I've had a long-term interest in humor, and a brief career as an unpaid stand-up comic in L.A. (Brief because my bombing to "killing" ratio was about 15 to one.)

With respect to my experience as a therapist, I now occasionally utilize humor in my treatment, but only extremely judiciously, once I have gotten to know my client.

I learned my lesson early. At the beginning of my residency training, during my second session with a client, I commented that perhaps he felt like Groucho Marx when Groucho said that he wouldn't want to be a member of any club with standards low enough to accept him. I sat back, feeling as if I had made the interpretation of the century, and waited for a reaction. I got one. The client stormed out of my office and never returned. My supervisor later told me that, as I suspected, I had screwed up royally.

This memory resonates with Dinah's statement that it's the recipient's reaction to a joke or a comment that counts. So know thy audience, and know thyself. You're obviously on much safer ground if you make a joke about a community or an ethnic group that you belong to. We do, however, live in an era of enhanced sensitivities and political correctness, and need to be extra careful not to anger or offend.

With respect to the Youtube audio, I, like a number of your readers, have heard other versions and have become desensitized to it. Ironically, I read about a version of it being told by a psychiatrist moonlighting as a standup comic years ago. My immediate reaction was, "Keep your day job, doc!"

Since "Psychiatry Hotline" is available to a large and varied audience, including people suffering from mental illness, I would not personally have posted it. Although it appears comparatively innocuous, I voted for it as offensive from a psychiatrist's point of view because it trivializes mental illness and is potentially hurtful to many.

Warmest regards,

Edward W. Darell, M.D.

Blog: ShrinqueRap (on Wordpad). Very soon to be updated. Please do not sue me. I registered the domain name before hearing of your blog, and my pockets are extremely shallow. (just short of being inside-out).

----------------And while we're on the subject of humor---- a nice break before I start writing about In Treatment tonight--- Sarebear sent us a link on A Proposal to Classify Happiness as a Psychiatric Disorder. Hmmm...it's a joke, right?And don't worry, Dr. Darell, we're not going to sue you, but do keep your day job.

Saturday, November 13, 2010

When I read books, especially psychiatry books that I write about on Shrink Rap, I often read more carefully and sometimes more critically. I was so immersed in reading Just Like Someone Without Mental Illness Only More So that I didn't stop to think, I just went on the journey.

Mark Vonnegut is a pediatrician and he is also the son of my favorite author from when I was in junior high school. His memoir is a poignant and candid account of his struggles with...well... life in general, and life with a psychotic illness in particular. Schizophrenia, bipolar disorder---who knows (I'll vote for bipolar disorder)? Some illness where he had three episodes in his twenties, then another episode 14 years later. Thorazine and lithium and megavitamins and psych wards. Xanax and alcohol and how humiliating it is to be psychotic on a stretcher in the ER hallway of the hospital where he works. Divorce and remarriage. First and second families. Childhood as the son of a financially struggling, not-yet-famous, eccentric writer, and adulthood as the son of an icon. Vonnegut is a hippy, a mainstream doctor, a middle-aged softball player, then finally a guy who accidentally poisons himself with wild mushrooms.

Dr. Vonnegut's struggles are those of vulnerability, fragility, hope, and resilience. He comes back from these life-altering episodes of psychosis and applies to 20 medical schools. He gets in to Harvard, and only Harvard. If you're going to apply to med school with a 1.8 science GPA from college, then I imagine it's helpful to have a very famous dad who teaches at Harvard. Vonnegut does well enough that he stays for residency and teaches there after. His illness and the possibility of its return hang on him--once you've heard voices, he says, you're never like someone who hasn't. As serious as the topic is, the author is able to make light of himself and the writing is funny and tragic all at once. It's a quick and engrossing read.

In case I didn't like this memoir enough, Vonnegut makes intermittent jabs about the tedious things that weigh down life as a doctor-- paperwork (my favorite rant), the influence of big pharma, and insurance companies.

So would I like Mark Vonnegut in real life? I liked him in his book. And so it goes.

Paul is upset that Adele doesn't have any Motrin to treat his headache. Adele doesn't recall his son's name fast enough. On the scoreboard, Adele is losing.
Paul gets up and walks around the room. Adele wants him to sit. He doesn't, at least not at first. He tells her a little about his patient, "You know what's going on here, it's perfectly obvious." But she doesn't. He wants her suggestions and Adele doesn't want to be both therapist and supervisor.

Paul talks about Max (his son, not my dog). He makes a lot of assumptions about....everything. Adele sums up the session by telling Paul that he has been pushing her to take care of him. She cites the evidence to prove her case.

Would Sigmund Freud or Carl Jung read Shrink Rap? Somehow, I'm not so sure. Tracey Cleantis seems a bit more certain. Check out her article on Blog.com of Top 10 Psychoanalysis Blogs (Jung and Freud would read).Thanks for the should out, Tracey, and we're always happy to be deemed accessible!

Jesse brings his mother to the session, but he doesn't want it known that he wanted her to come. Jesse continues to alternate between being a gentle, vulnerable boy and being a provocative, hurtful monster. He tells his mother about the sexual event, in all it's glorious detail, that got him beaten up and suspended from school, and just in case that's not enough, he announces that his birth mother wants him back. Mom gets upset and leaves the room. Paul asks her to stay. Why does he do that? When someone says "enough" or "I need space," maybe it makes sense to listen.

Paul tells Jesse he's creative, an artist. I like that, he's saying something to build the kid up. He tells Jesse that his own son is an artist and that sometimes he doesn't understand him and feels distant. Is this the right thing to do? At first it seemed kind, like an attempt to connect with Jesse, but for a moment I wondered who was the patient. The revelation doesn't seem to have an impact on Jesse, who is drowning in his own complicated life and problems. He wants so much to be loved and valued as he pushes the world away.

Paul asks Jesse if he's heard from, or contacted his birth mother, and Jesse abruptly stands and leaves. Paul follows him to the door, not just to say goodbye, but to continue the session as Jesse is trying to end. And Mom, who Jesse had believed would leave, is still in the waiting room.

Paul asks his girlfriend if he has 'happiness deficit.' She hasn't seemed to notice what a miserable creature he is.

Frances is a hurricane of stories about her mother, her daughter, and her sister. The sister, you'll recall, was once a patient of Paul's and the entire session is a play of who is having a relationship with whom and of competing jealousies. Mom liked sister more, even from infancy, and now daughter likes her dying sister more. Frances is always on the outside, always the one abandoned by everyone else, and on cue, Paul recalls how the patient used to put lipstick on her dying mother until the very end. Oops, Paul got the wrong patient, it's a story that the sister had told him 18 years ago! One more jealousy. And Frances wants Paul to help rehearse her lines, like her ex-husband used to do. He refuses and she storms out. Somehow, he feels more like the patient in this episode as he fumbles to apologize and cover his mistakes. Ah, the episode started that way when he fell asleep and the patient's knocking woke him--and he lied to conceal that he'd been asleep.

Usually, I find it easy to criticize Paul as a therapist. In this episode, however, I felt like I could relate to his mistakes. We all have moments where we slip--forget the name of a patient's spouse, confuse a story with one another patient told...he's put on the spot, and somehow I know how he feels. Yes, Clink, I know, it's just a TV show and they're not real.

So last week, I took my kid to the doctor. He knows I'm a psychiatrist and greeted me with "Have you ever watched In Treatment?" Oy. He wanted to talk about Sunil.

Sunil continues to develop as a character. He and Paul have tea. They talk about dignity and passion and living a principled life. Sunil is animated when he talks about Survivor and about his daughter-in-law as she exercises. He's overheard his son having sex with her, he thinks she's having an affair, and we learn that Sunil was secretly in love briefly, before he met his wife in an arranged marriage. Maybe he is jealous of his son, Paul suggests, or maybe he feels the daughter-in-law is betraying Sunil personally.

Who is Sunil? Is he laughing or is he crying? Is he wise or is he insane? There is a mystery to him--- he wants to know exactly what might cause Paul to break his confidence, and as Paul tells him that the circumstances would have to be extreme, that someone would have to be in danger, it's hard not to wonder if someone might be. Sunil is compelling, yet creepy, and one might wonder if he's attracted to his daughter-in-law, or if he's thinking of killing her? Did anyone else wonder this?

Sunday, November 07, 2010

I've decided to start reading the Sunday New York Times in bed--- no electronic distractions and I actually sort of read. I love the internet, but I think it makes me crazy.

The NY Times has a feature on Debra Winger and talks about her acting come back in the role of Frances on In Treatment. Click here if you'd like to read it.

I'm reading a wonderful book, a memoir by Dr. Mark Vonnegut called Just Like Someone With Mental Illness Only More So. When I was a kid, I loved Kurt Vonnegut's novels. Unusual family with lots of genius and mental illness. I will write more about the book when I finish it, maybe later today?

Tried a great new pizza place last night. Trouble parking and I thought I'd never go there again, and then we ordered a boring pizza because we have topping-issues in my marriage. Great spinach salad, and as we waited for the pie, I coveted the pizza's around us with sausage, veggies, mushrooms, oh.... but then our Four Cheese Pizza arrived and it was amazing. We didn't even mind that we were by far the oldest people in the place, and I will definitely go again, maybe on a weekday. So here's a plug for Iggy's.

As for the rest of my day? Roy wanted me to go to lunch with him so he could convert me into someone who fully understands the details of an issue that has come up in our state with hospital reimbursements. The restaurant he chose isn't open on Sundays. Oh, and he's decided he's busy with one of his many other projects. Clink wanted to work on posting another podcast with me, but got a last minute invite to a birthday party and has blown me off. I've pointed out to her that she was on my "A" list as a first-choice friend for a Sunday afternoon. The day-before birthday party invite and she was clearly on that person's "B" list. Apparently, my company doesn't compare to the prospect of birthday cake.

Our little dog, Kobe, the hyperactive one, was shaved down yesterday in an event called grooming. I suggested husband take him to the Ravens Game (Kobe would like that) but was told, "As a comfort dog? Kobe is the farthest thing from a comfort dog."

Friday, November 05, 2010

Today, I went to work at my office, and mostly, I saw me. All of my patients either didn't show up or canceled their appointments, except, of course, for my last patient. It was a really weird day.

I don't have an internet connection in the office and I don't have a TV. I don't even have a desk. My office mates weren't there. It was me. I made phone calls. I texted my friends. I vacuumed the carpet. I made hot tea. I talked to Clink. I thought about Roy. I listened to NPR on the radio in the waiting room. I went to lunch at a cafe in the neighborhood, chatted with the owners and checked my email on the free WiFi. I rested on the couch. It was all kind of serene. In my younger days, I would have been upset, and if I had my car, I probably would have gone home and fiddled on the Internet and done housework. I saw my last patient who said, "You should go home now, it's Friday." I did. As I locked up the office, I thought, well I didn't have to cook and I didn't have to do laundry and with limited on-line access, it was sort of like being on vacation.

Thursday, November 04, 2010

He talks about how awkward it is to be a called to consult on a patient who is on a medical or surgical unit of a hospital when the patient hasn't been told that a psychiatric consult has been requested. The Shrink gets to announce to the surprised patient that they were called and the patient may be insulted.

What’s troubling about this all-to-common scenario is that when consultations are requested of psychiatrists, two key ingredients are often missing. First, the reason for the consultation is often unclear. Second, the consultation is often requested either without the patient’s permission or knowledge, or, the patient is informed of the consultation but an inadequate or even inaccurate, potentially insulting explanation is given.

Roy is our C-L Psychiatrist here at Shrink Rap, so I'll let him add to the comments. As an outpatient psychiatrist, I'm just never a surprise.